REVIEW ARTICLE

Jose
F. Siqueira, Jr., PhD,*†‡

Dens Invaginatus: Clinical Isabela N. Ro^ças, PhD,*†‡
Sandra R. Herna
ndez, MSc,*‡§
Implications and Antimicrobial Karen Brisson-Sua
rez, DDS,*‡k
Alessandra C. Baasch, DDS,*‡k
Endodontic Treatment Alejandro R. Pe
rez, PhD,†‡¶ and

vio R. F. Alves, PhD*†
Fla
Considerations

ABSTRACT
SIGNIFICANCE
Dens invaginatus or dens in dente is a developmental dental anomaly resulting from an
invagination of the enamel organ into the dental papilla during odontogenesis. The present narrative updated
Radiographically, it is usually seen as a radiolucent invagination surrounded by a radiopaque and expanded the discussion
area (enamel) limited to the tooth crown or extending into the root. Because the invagination is about the endodontic
opened to the oral cavity, it can retain saliva, food remnants, and bacteria. In conditions where implications of dens
the enamel lining of the invagination is naturally absent or lost because of caries, bacterial cells invaginatus as well as the
and products can diffuse from the invagination through the dentin tubules to reach the pulp current treatment
and cause disease. Management of teeth with dens invaginatus includes preventive sealing or recommendations based on
filling of the invagination, or if the pulp is affected, therapeutic options include vital pulp anatomic considerations and
therapy, nonsurgical root canal treatment, apexification or regenerative endodontic new technologies.
procedures, periradicular surgery, intentional replantation, or extraction. It is recommended
that the invagination be always approached, regardless of the type of dens invaginatus. The
root canal should be treated whenever the pulp is irreversibly inflamed or necrotic. Endodontic
management of teeth with dens invaginatus is often tricky because of its anatomic complexity,
and special and customized strategies should be devised. This review discusses the
endodontic implications of this anomaly and the current treatment recommendations based
on anatomic, pathological, and technologic considerations. (J Endod 2022;48:161–170.)

KEY WORDS
Apical periodontitis; dens invaginatus; root canal infection; root canal treatment From the *Postgraduate Program in
Dentistry, University of Grande Rio
(UNIGRANRIO), Rio de Janeiro, RJ, Brazil;
†
Dens invaginatus or dens in dente is a developmental malformation that radiographically looks like one Department of Dental Research, Faculty
tooth inside another one, which has inspired the terminologies used to define this condition1. Although its of Dentistry, Iguaçu University (UNIG),
Nova Iguaçu, RJ, Brazil; ‡Endochat
etiology is controversial and several theories try to explain its formation1,2, it is widely accepted that dens
Research Group, Rio de Janeiro, RJ,
invaginatus may result from an invagination of the enamel organ into the dental papilla during Brazil; §Department of Endodontics,
odontogenesis, before calcification occurs.1 External factors such as trauma or infection may also Francisco Marroquín University,
influence its development3,4. The occurrence of dens invaginatus may be related to genetic factors3,5, but Guatemala City, Guatemala; kDepartment
research in this field is still limited. of Endodontics, Santa María University,
Caracas, Venezuela; and ¶Department of
Dens invaginatus is among the most prevalent developmental tooth anomalies. Its prevalence in
Endodontics, University Rey Juan Carlos,
permanent teeth varies from less than 1% to 10%, depending on the population studied3. Genetic factors Madrid, Spain
related to ethnicity may be the reason for differences in prevalence in diverse geographical areas. Bilateral
Address requests for reprints to Dr Fl
avio
occurrence affecting contralateral teeth is not uncommon6,7, representing 43% of the cases8. The R. F. Alves, Rua Professor Jose
de Souza
maxillary lateral incisor is the most affected tooth, followed by the maxillary central incisor, canines, and Herdy, 1160, Duque de Caxias, RJ, Brazil
premolars1,4,9. The occurrence of dens invaginatus in molars is rare.10 Primary teeth can also exhibit this 25071-202.
anomaly11. E-mail address: flavioferreiraalves@gmail.
com
Because dens invaginatus is frequently associated with pulp and periradicular diseases, 0099-2399/$ - see front matter
endodontic management is often required to save and treat the affected tooth, but it is frequently
Copyright © 2021 American Association
challenging because of the variable and aberrant anatomy3,12–14. The purpose of this narrative review is of Endodontists.
to update and expand the discussion about the endodontic implications of dens invaginatus as well as https://doi.org/10.1016/
the treatment recommendations based on anatomic considerations and new technologies. j.joen.2021.11.014

JOE  Volume 48, Number 2, February 2022 Dens Invaginatus: Treatment Perspectives 161
CLASSIFICATION
There have been some attempts to categorize
the different manifestations of dens
invaginatus. The first one was proposed by
Hallett15 in 1953 and included 4 types mostly
based on the invagination morphology.
However, the most widely used classification
was described by Oehlers13,14 in 1957, which
included 3 types based on the vertical
extension of the invagination (Fig. 1). Oehlers’
type I consists of an invagination that is limited
to the tooth’s crown and does not penetrate
the root. In type II dens invaginatus, the
invagination extends through the root and
ends in a blind sac without communication
with the periodontium. In type III, the
invagination goes all the way from the crown
opening up to the periodontal ligament laterally
(subtype IIIa) or apically (subtype IIIb), forming
an additional lateral or apical foramen,
respectively.
Oehlers’ classification is simple and
helpful to guide treatment planning. It
distinguishes between complete (type III) and
incomplete invagination (types I and II), which is
of great relevance because the management
of each one can be very different. A limitation of
this classification is its bi-dimensional nature,
especially nowadays when advanced three-
dimensional imaging examination has become
widely available and can play an important role
in improving the management of teeth with
complicated root anatomy16,17.
A radicular variety of dens invaginatus
has been reported18, with 2 types being
identified. One is characterized by a
cementum-lined invagination in the root; its
FIGURE 1 – Oehlers’ classification of dens invaginatus. (A ) Type I. (B ) Type II (courtesy In^es Inojosa). (C ) Type III.
162 Siqueira Jr. et al.
morphology and clinical characteristics are
entirely different from other forms of dens
invaginatus. This is currently referred to as
palatogingival groove or radicular groove. The
second type is characterized by an enamel-
lined invagination involving only the root, with
only a few cases reported in the literature19.
The coronal type of dens invaginatus is by far
the most common variety and as such is the
subject of this review.
DIAGNOSIS
Unless the patient presents with pain and/or
swelling associated with the involved tooth,
dens invaginatus is commonly diagnosed as
an incidental radiographic finding. In addition,
although some teeth with dens invaginatus
may have a normal appearance, most cases
exhibit an atypical crown, with a conical, peg-
shaped, barrel-shaped, or dilated morphology,
or have a bifid exaggerated cingulum.
Consequently, it is recommended that the
clinician performs a radiographic examination
of teeth with an abnormal crown anatomy to
check for the possibility of dens invaginatus or
other anomalies19.
Dens invaginatus can also be a
diagnostic problem and may be suspected
when the patient presents symptoms of
pulpitis in a tooth without a history of trauma or
caries. Ricucci et al10 reported on a case of
complicated diagnosis in which the cause of
pulp inflammation and necrosis was dens
invaginatus that was only detected after
extraction and histopathological analysis. In
teeth with dens invaginatus, the results of pulp
sensitivity tests depend on the dental pulp
conditions; the invagination does not respond
to pulp sensitivity tests because it does not
contain a vital innervated tissue. Sometimes
the tooth with dens invaginatus can present an
apical periodontitis lesion but still responds to
the sensitivity tests. This indicates that infection
is established in the invagination that
communicates with the periradicular tissues
(Oehlers’ type III) but has not affected the pulp
significantly.
Radiographic examination is essential to
a correct diagnosis of dens invaginatus. The
invagination usually appears as a radiolucent
pocket lined by radiopaque borders (enamel)
and is either confined to the crown or extended
into the root. Communication between the
invagination and the apical or lateral
periodontal ligament may be evident and
associated with a periapical or lateral bone
radiolucency20.
Nevertheless, conventional periapical
radiographs are usually of limited diagnostic
information because they show only a bi-
dimensional view of the very complex anatomy
of dens invaginatus. In cases where dens
invaginatus is identified or suspected, cone-
beam computed tomography (CBCT) has
become an invaluable tool to define the
invagination type, establish its three-
dimensional spatial relationship with the tooth
anatomy and the pulp space, and plan the best
treatment strategy (Fig. 2)17,21.
In CBCT axial sections, the invagination
is often seen as a canal lined by a radiopaque
enamel circle (Fig. 3). It can exhibit several
different configurations, and the presentation
JOE  Volume 48, Number 2, February 2022

FIGURE 2 – CBCT images of teeth with dens invaginatus types II (A, courtesy Marcelo Sendra) and III (B, courtesy
Patricia Ferrari).
can vary even among the different cross
sections of the same tooth from the coronal to
the apical third of the root. For instance, the
invagination may be located centrally in the
root, and the true canal can be displaced in a
buccal or palatal/lingual direction, often
assuming a C-shaped morphology (Fig. 4).
Other times the invagination appears as
another canal in the root (Fig. 4). In many teeth
with types I and II, the true root canal assumes
a rather normal morphology in the root portion
apically to the invagination.
Combined with clinical examination,
CBCT is of great value to a differential
diagnosis between dens invaginatus and
palatal radicular groove. Both entities may
exhibit grooves deriving from the cingulum22.
However, the presence of a hyperdense image
inside the tooth (enamel lining of the
invagination) in CBCT slices is highly
suggestive of dens invaginatus.
FIGURE 3 – Axial CBCT sections showing the invagination lined by enamel (A, courtesy Marcelo Sendra; B, courtesy Patricia Ferrari).
JOE  Volume 48, Number 2, February 2022
INVAGINATION OR
PSEUDOCANAL
The main feature of dens invaginatus is the
occurrence of an invagination that is opened to
the oral cavity. The entrance of the invagination
on the crown may appear like a pit, groove, or
deep foramen cecum on the palatal or occlusal
surface of the tooth, in many cases affected by
caries19,23. On rare occasions, the opening
can be found in other areas such as the buccal
face of the tooth crown (Fig. 5).
If narrow and small, the invagination
opening can be difficult to detect during
inspection, mainly when bacterial plaque or
food accumulates on its opening, preventing
visualization. The operating microscope and
stains may be valuable tools for the detection
of the dens invaginatus opening.
The invagination is like a pseudocanal
with the walls lined by enamel. The enamel
lining may not be uniform, exhibiting
interruptions and pits, or it can be lost as a
result of caries, resulting in a direct
communication of dentin or even the pulp with
the lumen of the pseudocanal4,24. Before tooth
eruption, the invagination is filled by remnants
of the dental papilla or the enamel epithelium25.
After eruption, the invagination can be filled
with saliva, food remnants, and bacteria.
Bacterial colonization and accumulation in the
invagination, with or without caries formation,
represent a serious risk for adverse pulp
reactions, including inflammation, necrosis,
and infection.
GENERAL TREATMENT
CONSIDERATIONS
The management of teeth with dens
invaginatus varies according to the
invagination extent (Oehlers’ type), pulp and
periradicular status, and the stage of root
development. Therapy includes preventive
sealing/filling of the invagination, nonsurgical
root canal treatment, apexification or
regenerative endodontic procedures,
periradicular surgery, intentional replantation,
or extraction. In virtually all cases of dens
invaginatus, it is recommended to approach
the invagination, regardless of the pulp
condition, either to prevent pulp pathology or
to help treat a tooth with necrotic pulp with or
without apical periodontitis.
Early detection of dens invaginatus
prevents future complications. If this condition
is suspected or confirmed by imaging
examination, inspection with the aid of a stain
such as methylene blue and magnification by
an operating microscope can facilitate the
detection of the coronal opening of the
invagination. In general, if the pulp sensitivity
tests and the clinical and radiographic
Dens Invaginatus: Treatment Perspectives 163
FIGURE 4 – Axial CBCT sections. (A ) The true root canal is displaced by the invagination and assumes a C-shaped morphology (courtesy Jorge Alberdi). (B ) The invagination appears
as another canal. (courtesy Florencia Cires).
conditions indicate that the pulp is vital and not
inflamed, the recommendation is just to seal
the entrance of the invagination or perform a
minimal preparation with a small bur and fill it to
prevent saliva penetration and bacterial
colonization.
Every single case of dens invaginatus is
different from the others, so any
standardization of treatment approach is
complex and may not suffice to deal with the
different conditions properly. Therefore,
anatomy-based planning is essential for
success and requires a good imaging
diagnosis. Radiographs and CBCT are
essential tools to plan the access preparation
and other treatment strategies. Evaluation of
pulp vitality and the presence of a periradicular
inflammatory lesion will guide the decision-
making process for adequate management.
New technologies such as guided
endodontics26 and computer-aided dynamic
navigation27,28 may be used for planning and
more accurate management of dens
invaginatus. The use of a guided endodontic
technique for managing maxillary lateral
FIGURE 5 – Opening of the invagination occurring on the buccal side of the crown. (courtesy Santiago Di Natale).
164 Siqueira Jr. et al.
incisors with dens invaginatus has been
reported29.
The preparation of the access cavity is
an important technical difficulty because of the
location of the pulp chamber and the
invagination (Fig. 6). The invagination in most
cases should be included in the final access
preparation shape together with the pulp
chamber (Fig. 7). In some instances, the
invagination may be entirely removed by using
an ultrasonic instrument to facilitate root canal
access30. There are also instances where 2
access cavities are prepared, one for the
invagination and the other for the true
canal29,31. Magnification by the operating
microscope can be of great value for access
preparation in teeth with dens invaginatus.
Even more challenging is to perform
chemomechanical preparation of both the
invagination and the true canal. Both have
irregular anatomy that is difficult to clean,
disinfect, and fill. In most teeth with type II and
all teeth with type III, the invagination should be
treated as a root canal. Rotary instrumentation,
preferably using conforming (adjustable)
instruments, aided by hand instruments, may
be necessary to improve cleaning and shaping
in many cases. However, the very complex
anatomy may require supplementary
disinfection steps after chemomechanical
procedures, including activation of sodium
hypochlorite (NaOCl) by mechanical (XP-Endo
Finisher, FKG Dentaire, La Chaux-de-Fonds,
Switzerland), sonic (EndoActivator, Dentsply
Sirona, Tulsa, OK) or ultrasonic means and an
interappointment intracanal medication32.
An intracanal medication with calcium
hydroxide paste represents an effective
approach to improve disinfection of the root
canal system after preparation33–36. Adding a
radiopacifier to the calcium hydroxide paste
may be indicated to reveal whether the paste is
reaching the irregularities of both the true canal
and the invagination (Fig. 8). If the vehicle used
is distilled water, saline, or camphorated
paramonochlorophenol/glycerin, it is
recommended to remove the paste 7–14 days
after application by irrigating with NaOCl and
using the master apical file or one size
larger37,38. This is because studies showed
that pretreatment with calcium hydroxide
makes the organic tissue more prone to
dissolution by NaOCl39,40, not to mention the
antibacterial effects of an additional NaOCl
irrigation37. If chlorhexidine is the vehicle for
calcium hydroxide, paste removal should be
conducted by copious irrigation with a
chlorhexidine solution.
In dens invaginatus types II and III, both
the canal and the invagination should be
obturated preferably with a thermoplasticized
technique for better filling of the anatomic
irregularities41,42. The invagination may
alternatively be filled with mineral trioxide
aggregate (MTA) or other bioceramic
materials43,44. If not eliminated during access
preparation, type I invagination can be filled
with a permanent restorative material.
If the pulp is necrotic and the apex is
open, apexification or a regenerative
JOE  Volume 48, Number 2, February 2022

FIGURE 6 – Access cavity showing the true root canal with a C shape and the invagination. (courtesy Santiago Di
Natale).
procedure is indicated to stimulate apical
closure, preferably by continued root
formation45–47. In cases where apexification is
the treatment of choice, it can be done by
placing an apical barrier with MTA or other
bioceramic material44,48 after at least 1 week of
calcium hydroxide medication to improve
disinfection. Another option is a long-term
calcium hydroxide treatment until root closure
is observed.
If the root is too short and/or has thin
walls, regenerative endodontic procedures
might be the first treatment option. The main
indications involve teeth with Cvek’s stages 1
to 3 of root development, ie, from less than one
half of root formation to two thirds of root
development with open apex49. This is
because the regenerative procedures can
result in thickening of the canal walls and/or
continued root development. Immature teeth
FIGURE 7 – (A–C ) Management of type II dens invaginatus in which the invagination was incorporated in the final canal preparation. (courtesy Laura Lavigne).
JOE  Volume 48, Number 2, February 2022
at stage 4, which show nearly completed root
formation with an open apex, can be managed
with either regenerative endodontics or
apexification50. There have been reports of
dens invaginatus types II and III in immature
teeth treated by regenerative procedures51,52.
According to the American Association of
Endodontists, the main criteria to consider
regenerative endodontic procedures as
successful involve eliminating symptoms,
evidence of bone healing, and increased root
wall thickness and/or increased root length53.
In cases where nonsurgical root canal
treatment fails or is not even feasible,
periradicular surgery using MTA (or other
bioceramic material) as the root-end filling
material is indicated to save the tooth and
restore the periradicular health54,55. In type III
dens invaginatus, root-end preparation and
filling of the invagination should also be done. It
is advisable to clean the irregularities of the root
canal and the invagination with ultrasonics
before placing the root-end filling. Antimicrobial
photodynamic therapy has also been shown to
improve disinfection of both the resected root
surface and root-end cavity during apical
surgery56. In cases of surgical failure,
intentional replantation may be indicated as the
last attempt to save the tooth57.
TREATMENT
RECOMMENDATIONS IN
SPECIFIC CASES
Different approaches are recommended for
the different conditions (Fig. 9).
Type I Dens Invaginatus
Vital Pulp
Non-inflamed pulp. If the pulp is vital and
healthy, it is advisable to seal the invagination
to prevent further problems. This can be done
by using acid-etched fissure sealant or
flowable composite resin material to seal the
entrance of the invagination or to fill it (after
preparing a small cavity) with resin or glass
ionomer. If caries is detected in the
invagination, this should be removed by using
round (if necessary long-necked) burs and/or
ultrasonic tips under magnification and
abundant illumination. Follow-up is essential to
regularly monitor the tooth for pulp health and
the restoration status58.
Inflamed pulp. If the pulp is vital but
diagnosed as with irreversible pulpitis, root
canal treatment is indicated. Because bacterial
infection of the invagination is the most likely
cause of pulp inflammation, it should be
cleaned and disinfected before being filled and
sealed. Ultrasonic tips can be used for this
purpose. The true root canal should be
Dens Invaginatus: Treatment Perspectives 165
 treated, preferably in a single visit. Because the
invagination is restricted to the crown, the root
canal anatomy is usually non-complicated, and
treatment does not represent a big challenge.
In teeth with an open apex, conservative pulp
therapy is indicated (pulp capping or
pulpotomy).

Necrotic Pulp
If the pulp becomes necrotic and apical
periodontitis develops, both the invagination
and root canal should be treated. The
invagination should be approached as
reported for teeth with irreversible pulpitis.
However, disinfection of the true root canal is
also essential for a favorable outcome and may
require the use of intra-visit and/or inter-visit
supplementary disinfection approaches. Teeth
with an open apex should be treated by
regenerative endodontics or apexification.

Type II Dens Invaginatus

The root canal system of teeth with type II dens
invaginatus is usually not as complex as that of
teeth with type III. In type II, the invagination
penetrates the root and ends in a blind sac; it
may assume either a lateral or a centered
position in relation to the true root canal. In the
FIGURE 8 – A radiopacifier has been added to the calcium hydroxide paste to improve observation of the filling of both former condition, the clinician usually does not
true canal and invagination. (courtesy Gabriela Martin). have difficulties to access and treat the true

FIGURE 9 – Recommendations for management of teeth with dens invaginatus in different clinical conditions. Suggestive approaches are shown to deal with both the root canal and
the invagination for the 3 types of dens invaginatus. AP, apical periodontitis; RC, root canal; RCT, root canal treatment; REP, regenerative endodontic procedures.

166 Siqueira Jr. et al. JOE  Volume 48, Number 2, February 2022

FIGURE 10 – In some cases of type II dens invaginatus with apical periodontitis, the apical terminus of the invagination
has to be perforated to permit better access to the infection in the apical part of the true root canal. (courtesy Patrícia
Ferrari).
canal. However, in the latter, the invagination
usually “pushes” the true canal to the buccal or
palatal/lingual root aspect, which presents a C
shape around the invagination. Apically to the
terminus of the invagination, the true canal
usually assumes a natural round or oval
morphology.
In some cases, the canal lumen in the C
shape lateral to the invagination is so narrow
that it is not negotiable with endodontic
instruments. Consequently, in these cases, the
clinician may perforate the apical terminus of
the invagination to get access to the apical part
of the true canal (Fig. 10). In other instances,
FIGURE 11 – Treatment of both the root canal and the invagination in a type III dens invaginatus with apical peri-
odontitis. (A ) Preoperative and (B ) post-obturation images. (courtesy Cristina de La Roca).
JOE  Volume 48, Number 2, February 2022
depending on the extent, volume, and position
of the dens invaginatus, the invagination can
be entirely removed by using ultrasonic tips
under magnification with the operating
microscope2,59. However, treatment of the
invagination and the true canal separately has
been reported54,60 and is a better approach to
preserve tooth structure.
Vital Pulp
Non-inflamed pulp. As with type I, if
the pulp is vital and healthy, only filling and
sealing the invagination are indicated.
Management of the invagination can be more
complicated depending on how deep it
extends into the root. The entrance of the
invagination should be enlarged by using
diamond burs or ultrasonic tips to permit
access for debridement. If caries is detected at
the entrance of the invagination, treatment
should be as reported for type I. Ultrasonic tips
and/or endodontic instruments associated
with NaOCl or chlorhexidine irrigation should
be used to clean the entire extent of the
invagination. Next, the invagination should be
filled with gutta-percha/sealer, MTA, or
another bioceramic material or a restorative
material (composite or glass ionomer). If pulpal
exposure is suspected, already exists, or
develops during the cleaning steps, the
invagination should be preferably filled with
MTA or another bioceramic material, which
has been successfully used for vital pulp
therapy61,62. Alternatively, the clinician may
decide on performing nonsurgical root canal
treatment in these teeth with pulp exposure.
Eventually the coronal part of the invagination
should be restored appropriately.
Inflamed pulp. Both the invagination
and the true root canal should be treated.
Special strategies, as discussed above, may
be necessary to reach the true apical canal. In
immature teeth, vital pulp therapy is indicated.
Necrotic Pulp. When apical periodontitis is
detected and the pulp is necrotic, both the
invagination and the true root canal should be
treated separately if possible. However, in
many cases, the invagination and the true
canal need to be united to permit better access
to the apical root canal. Because the anatomy
is very complex and complicated in these
cases and disinfection of the true root canal is
paramount for a successful outcome, most of
the strategies discussed above should be
used, including CBCT-based planning,
magnification with the operating microscope,
supplementary disinfecting procedures, and
thermoplasticized obturation. If the apex is
immature, the clinician may opt for either a
regenerative endodontic procedure or
apexification.
Type III Dens Invaginatus
Most considerations for type II are also applied
to type III dens invaginatus. One important
exception is that the invagination directly
contacts the apical or lateral periradicular
tissues, and the treatment outcome will also
depend on the proper management of the
invagination. When apical periodontitis is
present but the pulp is vital, then the cause of
periradicular inflammation is bacterial infection
of the invagination space. However, if the pulp
is necrotic and apical periodontitis is detected,
Dens Invaginatus: Treatment Perspectives 167
it is clinically impossible to define whether the
invagination, the true canal, or both, is the
cause. Therefore, a successful outcome will
rely on proper disinfection of both.
Vital Pulp
Non-inflamed pulp. If the pulp is vital
and non-inflamed and there is no apical
periodontitis, the management should be just
preventive, as reported for the other 2 types.
Cleaning, disinfecting and filling the
invagination are of utmost importance to
preserve pulpal vitality63–65. However, it is
salient to point out that unlike the other types,
in type III dens invaginatus, apical periodontitis
may be present in a tooth with vital non-
inflamed pulp. In these cases, the cause of the
periradicular inflammatory lesion is bacterial
infection of the invagination, which should be
cleaned, shaped, disinfected, and filled like
true root canals, with attention to its commonly
aberrant anatomy. Pulp vitality of the true canal
can be preserved, and treating only the
invagination can result in periradicular
healing66.
Inflamed pulp. Both the true root
canal and the invagination should be treated. In
teeth with an open apex, pulpotomy may be CONCLUSIONS
the best approach for the inflamed pulp,
Dens invaginatus is a developmental anomaly
whereas the invagination should be treated as
that predisposes the tooth to pulp and
a root canal.
periradicular diseases. If endodontic
Necrotic Pulp. Both the invagination and the treatment is required, it can be very
true root canal system should be treated, with challenging because of the anatomic
special emphasis on strategies to deal with complexity inherent to these cases.
bacterial infection in the complex anatomy of Therefore, it is important to understand the
both (Fig. 11). Ideally, the canal and different manifestations and conditions that
invagination should be treated separately, but the clinician may face when dealing with this
sometimes they are inevitably communicated anomaly to apply therapeutic strategies that
during preparation. Type III dens invaginatus are more predictable to successfully treat and
cases with pulp necrosis and apical save teeth with dens invaginatus.
periodontitis are the most difficult to treat
because the complex anatomy of both the root
canal and the invagination makes cleaning,
shaping, and disinfection very difficult. ACKNOWLEDGMENTS
Therefore, the special treatment strategies to
This study was supported by grants from
enhance infection control mentioned in the
Fundaça ~o Carlos Chagas Filho de Amparo a 
previous section are required to improve the
Pesquisa do Estado do Rio de Janeiro
chances for a satisfactory outcome, which is to
(FAPERJ) and Conselho Nacional de
save the tooth while maintaining it functional
Desenvolvimento Científico e Tecnolo
gico
and surrounded by healthy periradicular
(CNPq), Brazilian governmental institutions.
tissues. If the apex is immature, regenerative
The authors deny any conflicts of
endodontic or apexification procedures are
interest related to this study.
indicated according to the stage of root
development and root wall thickness.

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